A 36 year old female with a painful, rapidly progressive breast ulcer. ID Case Conference Wednesday, April 11 th , 2007 David Fitzgerald, MD. HPI.
Download Policy: Content on the Website is provided to you AS IS for your information and personal use and may not be sold / licensed / shared on other websites without getting consent from its author.While downloading, if for some reason you are not able to download a presentation, the publisher may have deleted the file from their server.
ID Case Conference
Wednesday, April 11th, 2007
David Fitzgerald, MD
Medications breast ulcer.
Clindamycin 300 mg q.8h. Begun 2 days prior.
Levothyroid 112 mcg once daily,
Bactrim – resp distress
Vanco – rash, ? Fever
Daptomycin – Rash
Linezolid - RashMedications/Allergies
Pleasant young woman in moderate distress breast ulcer.
T 39.7 P 140 BP 90/60, RR 18, Sat 98% RA
HEENT Perrla, EOMI, anicteric, mucous membranes dry
Lymph – no cervical, sc lan
CV – Tachy, regular, no mrg
Lungs – CTAB
Breast – R breast with 7 x 8 cm area of necrotic tissue with dark edges and 1-2 cm surrounding erythema. Purulent drainage from wound but no appreciable deep abscess. Exceedingly tender to palpation.Physical Exam
WBC 24 K breast ulcer.
Basic WNL with BUN/Cr of 18/0.8
Wound swab – 2+ PMNs, no organisms, no growth.
BCX x 2 – No growth
Ucx – no growth
Prior breast abscess from 5 days prior revealed MRSA sensitive to clinda (negative for inducible resistance), bactrim, vancomycin, gentamicin and tetracyclineData
Surgical path breast ulcer.
“The two previous debridements have been reviewed. The morphologic appearance of all three lesions is similar, showing large aggregatesof neutrophils accompanied by epidermal ulceration. Previous special stainshave been negative for bacteria, fungi, and AFB. “
Multiple surgical gram stains and cultures revealed 2 + PMNS, no organisms and no growth.
One surgical culture grew coag neg Staph.Pathology and further micro
All cxs remained negative except for one surgical cx with CNS
At recommendation of derm, pt was started on prednisone and antibiotics were eventually stopped with halt of progression of necrosis
Pt seen in follow up one week after d/c off abx and on prednisone 100 mg daily with clean wound edges and no evidence of purulence
Seen also by GI for planned colonoscopy
1. Non-infectious dermal neutrophilia,
2. Usually an associated condition (inflammatory bowel disease, paraproteinemia, or arthritis),
3. A tendency for pathergy -
4. Similarities in treatment (prednisone and dapsone)